Psychiatry 2 Flashcards
Binge eating disorder Sx?
Recurrent binge eating with lack of control but NO compensatory behaviors (vomiting, excessive exercise, etc.)
What is the best management route in Pts who respond well to oral antipsychotics, but are poorly compliant resulting in relapse?
Long-acting injectable antipsychotics.
Low levels of what is found in the CSF of those with narcolepsy?
Hypocretin-1
Management of delusional disorder?
Antipsychotics
CBT
Pt taking fluoxetine for depression has poor responsiveness to the medication. She is started on phenelzine 3 weeks after stopping her previous SSRI. She has a nice meal with wine, cheeses, and seafood one night and the next day reports agitation, disorientation, diaphroesis, and tremor. She is febrile with high BP and pulse. Dx?
Serotonin syndrome. Fluoxetine requires a longer washout period (5 weeks vs normal 2 for other SSRIs) and mixed with phenelzine can lead to serotonin syndrome. The triad is AMS, autonomic dysregulation, and neuromuscular hyperactivity.
What AA results in poor rxn with MAOIs?
Tyramine.
Grief rxn differs from MDD after loss by what qualities?
Grief does not qualify for 5/9 SIGECAPS with depressed mood, though loss and emptiness are normal. The fxnal decline is less severe and feelgins of worthlessness, self-loathing, and guilt are less severe/common.
Man taking proper dose of SSRI for 2 weeks does not report any improvement to symptoms. Next step?
Continue present dose for at least 4-6 weeks
A mother and daughter are experiencing fear that their landlord is trying to poison them. The mother states she has seen the man lurking about their apartment at times and believes he has installed cameras in the apartment when they were gone. The daughter confirms these fears. Dx?
Shared psychotic disorder (delusional disorder) often called “folie a deux”. The first step is to separate the pair to disrupt the mutually reinforcing nature of the shared delusion.
What 3 steps can reduce opioid misuse?
Reviewing the state’s prescription drug-monitoring program data
Random drug tests
Regular followup
Help-rejecting patients require what efforts by the physician?
Empathy expression
Collaborative approach with small/limited goals.
A 14year old with >12 month Hx of stealing, fighting in school, truancy, and lying to their loved ones likely have what condition?
Conduct disorder. Aggression, cruelty to people/animals, destructive behavior, etc. are all typical symptoms. Violate societal norms/rights of others.
Conduct disorder and antisocial personality disorder have what in common?
Repetitive patterns of violating basic social norms and the rights of others. Individuals ≥18 years old receiving a Dx of antisocial personality disorder require prior Hx of conduct disorder under 15years old.
Sleep terrors course?
Usually resolve within 1-2 years. Provide reassurance or low dose benzo at bedtime if frequent.
Extrapyramidal signs are most common in first-generation antipsychotics due to D2 antagonism in what pathway?
Nigrostriatal pathway.
Which 2nd gen antipsychotic leads to highest risk of metabolic issues?
Olanzapine. Known to cause weight gain and metabolic effects. Especially avoid in DM.
Trazadone classic SE?
Priapism
Lithium SE
Kidney damage. DI.
Lamotrigine classic SE?
Stevens-Johnson.
Clozapine SE?
Neutropenia
Bupropion SE?
SZ
Weight loss
Valproate SE?
Elevated aminotransferases from liver failure (rare) often w/in 6 months of start of Rx.
Gifts from a patient in any sort of altered state due to their medical condition (delusions, mania, etc.) should be?
Declined. Gifts given 2nd to impaired judgement are not acceptable.
Pulmonary capillary wedge pressure is likely what in PE?
Normal or low. PCWP measures the left atrial pressure and may help differentiate PE from MI. If high, consider heart failure due to MI, but if low consider PE.
What is the progression of HIV dementia?
Early: Subcortical (BG, nigrostriatal) dysfxn leads to slow movements, difficulty with smooth limb movement.
Late: Cortical neuron loss (cognitive issues) and memory decline.
Adjustment disorder Sx?
Emotional or behavioral changes within 3 months of an identifiable stressor lasting no more than 6 months after stressor ceases.
How do acute psychiatric illnesses differ from personality disorders?
Personality disorders show lifelong patterns of behavioral issues.
Basic idea of schizoaffective disorder?
Psychotic symptoms during mood symptoms and in the absence of mood symptoms.
Schizoaffective and schizophrenia differ how?
Schizophrenia usually does not have severe mood symptoms as does schizoAFFECTive disorder. Affect refers to the mood symptoms.
MDD or bipolar disorder with psychotic features are similar in that?
Psychosis occurs exclusively during mood episodes.
Obsessive compulsive behaviors are primarily driven by alteration in what neurotransmitter?
Serotonin. Thus, SSRIs are the first-line.
Dopamine dysfxn is responsible for what psych issues?
Psychosis.
Primary fxn of GABA in CNS?
Inhibition.
Primary fxn of Glutamate in CNS?
Excitation.
First-line Rx for PCP intoxication?
Benzos. If this fails, then antipsychotics (haldol).
Displacement vs projection defense mechs?
Displacement transfers feelings to a more acceptable object or person (angry at kids instead of dangerous husband). Projection attributes one’s own unacceptable feelings onto others (man wants to have affair and says his wife wants one).
Buspirone use?
Non-benzo anxiolytic used in GAD. Best for use in those with high risk of abuse of benzos.
First line Rx in generalized anxiety disorder?
SSRI or SNRI.
RFs for schizophrenia include?
Obstetric complications (hypoxia, etc.), Cannibis use Birth in late winter/early spring (influenza infxn in mom) Immigration
Which antipsychotic is known for causing galactorrhea?
Risperidone
How can prolactinoma be differentiated from antipsychotic cause of galactorrhea?
Prolactinoma causes very high (>200ng/mL) levels of prolactin in serum.
Differentiate parkinson’s dementia from Lewy body dementia.
Parkinsons: motor issues first (predates dementia by ≥1 year)
Lewy body: dementia and hallucinations then parkinsonianism later
Depersonalization or derealization (disconnection from self or reality) occur in panic disorder when?
Only during panic attacks, otherwise, if they are occurring outside of attacks the pt may have derealization and depersonalization disorder.
Management of neuroleptic malignant syndrome?
- Stop antipsychotic and support the pt (cool, antipyretics, fluids, e-)
- If refractory, give Bromocriptine or amantadine or even dantrolene.
Lithium OD Sx?
GI sx AMS Ataxia Tremor Sz
Common causes of lithium OD precipitation?
Thiazides
ACEI
NSAIDs
Dehydration
What physical symptoms are common to generalized anxiety disorder?
Muscle tension
Restless
Fatigue
Standard drug tests do not detect what opioids?
Semisynthetics (hydrocodone, hydromorphone, oxycodone) or synthetics (fentanyl, meperidine, methadone, tramadol). Thus, despite having physical symptoms (low respers, small pupils, etc.) they may be negative on standard screen.
Tuberoinfundibular dopamine pathway?
From hypothalamus to the pituitary gland. Responsible for inhibition of prolactin via dopamine release.
Mesolimbic pathway?
Extends from ventral tegmental area (midbrain) to limbic system (instinct and mood control) near frontal cortex. This dopaminergic pathway is responsible for hallucinations/delusions in schizophrenia.
NIgrostriatal pathway?
Substantia nigra cells project dopamine into the stria (the basal ganglia) and when inhibited can cause parkinsonianism, akathisia, dystonia.
Mesocortical pathway?
Dopaminergic pathway leading from midbrain to cortex of entire brain.
Somatic-symptom disorder Rx?
CBT
SSRI
SE of mirtazapine?
Weight gain
Appetite stimulation
Sedation
MOA of mirtazapine?
Tetracyclic antidepressant (similar to tricyclic)
Kids aged 18-24 starting new antidepressants are at slight risk for?
Suicidality.
Gender dysphoria Sx?
Persistent (≥6 months) incongruence b/t assigned and “felt” gender
Management of gender dysphoria?
Assess safety of Pt and arrange for multidisciplinary medical/psych evaluation
50s male with depressed mood, fatigue, and anhedonia presents. His BMI is 40 and his wife recently moved out of the bedroom to sleep on the couch because of his snoring. He does not enjoy his work anymore because he frequently feels as through he will fall asleep at his desk and he is always tired. Dx?
Mood disorder due to another medical issue. Consider this in each case and look for other reasons (medical issues) that could be causing the mood issues. He likely has sleep apnea, which can mimic or overlap with depression.
Rx for social anxiety disorder?
SSRI/SNRI
CBT
Beta blocker (propanolol) or benzo for performance-only subtypes
Rx in performance-only subtype social anxiety disorder?
Beta blocker (Propanolol) or a benzo. ***If prior drug abuse Hx do not give benzos.
What is another name for social anxiety disorder?
Social phobia. This is significant because these people have significant anxiety about 1 or more social situations often fearing scrutiny of others. Hence, fear of social situations.
Basic idea of acute dystonia due to antipsychotics?
Sudden, sustained contraction
Basic idea of akathisia due to antipsychotics?
Restlessness
Basic idea of tarditive dyskinesia due to antipsychotics?
Gradual onset of unintentional movements
Testing required before lithium started in Bipolar?
BMP Calcium Thyroid Fxn Urinalysis ECG Pregnancy test ***Lithium causes nephrogenic DI, CKD, hyperparathyroidism with hypercalcemia, and thyroid dysfxn. Also it is a teratogen and can increase CV risks, hence, ECG.
Imaging finding in schizophrenia?
Enlargement of lateral cerebral ventricles
Decreased hippocampus/amygdala volume
First-line Rx for PTSD?
SSRI/SNRI
CBT (trauma focused)
Rx for nightmares in PTSD?
Prazosin (alpha blocker)
Cocaine withdrawal can lead to?
Acute depression
Suicidality
Hypersomnia, hyperphagia, and fatigue are common.
Brief psychotic disorder basic idea?
1 or more psychotic symptoms for a day to a month then returns to normal fxn
Pt has manic episodes only, but no known depressive episodes. Dx?
Bipolar 1
Pt. has episodes of elation with elevated mood and decreased need for sleep, but still fxns at work and at home. This has been followed by a major depressive episode. Dx?
Bipolar II
Pt reports years of fluctuating mood with high points of elation and decreased sleep, but then depressive symptoms that are not horribly severe. Dx?
Cyclothymia. Does not meet BP1 or 2 criteria (no full hypomanic or major depressive episodes).
Alcoholic hallucinosis Sx?
Alcohol withdrawal syndrome involving hallucinations. Develops in 12-24 hrs lasting 48 hrs after last drink. Unlike DTs, sensorium is intact (no confusion, agitation, etc.) and vitals are stable.
